Download bicipital tendonitis

BICIPITAL TENDONITIS
Lyn Paul Taylor, B.A., M.A., R.P.T.
(Editing Assistant and Computer Consultant: Joanna Soon, B.S.)
The biceps brachii muscle is formed from two heads placed along the anterior aspect of
the humerus. The short head originates as a thick flattened tendon from the apex of the
coracoid process that it shares with the coracobrachialis muscle. The long head
originates as a tendon from the supraglenoid tuberosity on the superior margin of the
glenoid cavity. This origin occurs within the shoulder capsule and the initial segment of
the tendon is enclosed in a synovial sheath. The tendon continues distally, arching over
the head of the humerus and running down the intertubercular groove (sulcus) under the
transverse humeral ligament and a fibrous prolongation from the pectoralis major tendon.
It emerges from the shoulder capsule close to the humeral attachment of the capsular
ligament, eventually attaching to its muscle belly. Each biceps head maintains a separate
identity until they are within approximately 7.5 cm of the elbow joint. At this point, they
become confluent and continue to end in a flattened tendon that inserts on the posterior
portion of the radial tuberosity. A broad aponeurosis arises from the tendon medially to
pass obliquely across the brachial artery, to become continuous with the deep fascia
covering the origins of the flexor muscles originating on the forearm.
Historically bicipital tendonitis has been defined as an inflammation of the tendon of
the long head of the biceps brachii. It occurs most commonly to women in their early
forties, but may occur to either gender at any adult age. An acute episode is generally
brought on by strenuous activity (skiing, tennis, shoveling) following on the heels of long
term wear and tear, degenerative changes in the tendon or the intertubercular groove
(roughening of the channel). Recent authorities have suggested that bicipital tendonitis
is misnamed and is, in fact, a bicipital tenosynovitis. They suggest that the inflammation
occurs to the tendon sheath within the bicipital groove and not to the tendon itself, and
offer as proof the frequent adhesions that form in the tendon's sheath.
Regardless of which structures are involved, bicipital tendonitis initially
demonstrates itself through pain when the arm is internally or externally rotated and
placed either behind the back or above the head. Usually the pain first occurs over the
anterior medial region of the shoulder and then radiates to the belly of the biceps muscle
and distal to the flexor surface of the forearm. Some subjects may complain of
additional pain radiating into the deltoid insertion, into the inferior angle of the scapula,
or to the base of the neck. Digital probing of the intertubercular groove will elicit
exquisite pain as will rolling the tendon between the fingers. The pain is aggravated by
active supination of the forearm against resistance and active contraction or passive
stretching of the biceps muscle.
The pain produced by bicipital tendonitis may limit the subject's ability to use the
shoulder. Functional activities may be curtailed insofar as the patient may be unable to
put on a shirt or lift anything that requires two hands. Even driving a car or brushing the
teeth may be difficult.
It should be noted that in spite of some orthopaedic opinions to the contrary,
differential skin resistance (DSR) survey has demonstrated that inflammation may also
occur to the short head's tendon. If it does, it usually occurs along with inflammation of
the long head tendon (though exceptions have been found). Generally, the inflamed zone
will extend distally two or three inches from the glenohumeral joint, and medially two
inches from the lateral margin of the intertubercular groove along the path of the
pectoralis major tendon (not pictured).
The high skin resistance pattern commonly associated
with Bicipital Tendonitis (of the lateral tendon)
Treatment
Treatment should be directed at relieving any inflammation, and eliminating any
adhesions, that may be present.
Application:
•
A DSR survey should be performed to establish the existence of any inflamed
zones.
•
The inflamed zone should be electrically stimulated. The electrical stimulator
should first be preset to deliver wide-pulsed galvanic current at six cycles per
second (Hz) for a ten-minute period. The negative electrode should be placed
over the inflamed zone and the positive over the lower trapezius muscle, on the
same side. The machine should be turned on and its amplitude gradually
increased to produce visible “bouncing” contractions of the biceps.
•
Following this stimulation, the electrical stimulation unit should then be preset to
provide a medium frequency waveform, with a duty cycle of ten-seconds on and
ten-seconds off. The electrodes should remain where they are. The stimulator
should be turned on and the amplitude gradually increased until brisk maintainedcontractions of the biceps can be observed. The stimulation should continue for
ten-minutes (refer to ELECTRICAL STIMULATION).
•
The inflamed zone, and adjacent tissues, should be manipulated to eliminate any
adhesions that are present. Successful manipulation should provide immediate
restoration of normal or near normal ranges of motion in the shoulder joint (refer
to SOFT TISSUE MANIPULATION).
•
Phonophoresis of an effective non-steroid anti-inflammatory should be
performed over the inflamed zone (topical ibuprofen is favorite). The ultrasound
unit should be preset to provide a 1 Mhz pulsed waveform, for six minutes, at 1.5
W/cm² (refer to ULTRAHIGH FREQUENCY SOUND, Precautions).
If bicipital tendonitis is the only component, the patient should, in most cases, be
completely relieved of the bicipital tendonitis syndrome in one or two treatment sessions.
Trigger Points:
The following trigger point formations may, singly or in combination, refer pain into
the areas usually affected by bicipital tendonitis: Levator scapulae, Scalenus, Scalenus
(minimus), Infraspinatus, Infraspinatus (abnormal), Medial teres major, Lateral teres
major, Coracobrachialis, Lower trapezius [A], Cervical multifidus (C4-C5),
Supraspinatus (muscle), Supraspinatus (tendon), Subclavius, Posterior deltoid, Anterior
deltoid, Pectoralis major, Pectoralis major (sternal portion), Pectoralis minor, Sternalis,
Rhomboids, Biceps brachii, Brachialis, Palmaris longus, Flexor carpi radialis,
Brachioradialis, Pronator teres, Multifidus (T4-T5), and Iliocostalis thoracis (T6).
References:
C.M. Goss, Gray's Anatomy, Lea and Febiger, Philadelphia, Pa., 1968. p. 463
Merck Manual of Diagnosis and Therapy, Merck & Co., Inc., Pittsburgh, Pa., 1968. p. 1267
R.B. Salter, Textbook of Disorders and Injuries of the Musculoskeletal System, Williams & Wilkins, Baltimore, Md., 1983. p. 243
W.N. Scott, B. Nisonson and J.A. Nicholas, Principles of Sports Medicine, Williams & Wilkins, 1984. p. 120
A.R. Shands and R.B. Raney, Handbook of Orthopaedic Surgery, The C.V. Mosby Co., Saint Louis, Mo., 1967. Pp. 425-426
L.P. Taylor, T. Hui, The Taylor Technique of Soft Tissue Management, Inflammation: Evaluation & Treatment, 2002. Pp. 252-254